Retinopathy Of Prematurity

ROP

Perinatology Division
Dept of Child Health, Medical Faculty
Hasanuddin University
Reproduction System
• The term ‘Retinopathy Of
Prematurity was first ROP
suggested by Heath in
1952

• Retinopathy Of Prematurity is a disorder of retinal

blood vessel development in the premature infant.
• The severe form is characterized by retinal vascular
proliferation, scarring, retinal detachment, and
blindness.
 Background
• Advances in neonatal care → survival rate of
preterm infants ↑ → incidence of ROP ↑
• Campbell 1951 suggested the possible role of
supplemental oxygen
• One of the most common causes of
irreversible childhood blindness
 ROP: Causes
Major Cause :
• Prematurity: It affects prematurely born
babies.
• All babies less than 1500 g birth weight
or younger than 32 weeks' Gestational
Age (GA) at birth are at risk of
developing ROP.
 ROP:Risk Factors
• Gestational age: less than 32 weeks
• Birth Weight: less than 1500 gm especially less
than 1250gms
• Oxygen therapy : Excessive oxygen use

Ref:The National Medical Journal of India: 1996; 9(5): 211-4.

 …. Risk factors
• Prolonged supplemental oxygen
• Unstable oxygen saturation level
• Vitamin E deficiency
• Light exposure
• Duration of ventilation therapy
• Respiratory disstress syndrome
Schaffer DB, et al. Ophtalmol 1993; 100: 230-7
Yang CS,et al. Chin Med J 2001; 64:706-12
Wheatley CM, et al. Br J Ophtalmol 2002; 86:696-701
Ikeda H, et al.Jpn J Ophtalmol 2004; 48:68-71
Allegaert K, et all. Bull Soc belge ophtalmol 2003; 287: 37-42
 Contd…
• Other factors :
 Sepsis,
 Multiple blood transfusions,
 Multiple births,
 Hyaline membrane disease,
 Use of aminophylline, antibiotics,
 Apnoeic spells,
 Low pH,
 Ultraviolet light therapy, etc

Ref:The National Medical Journal of India: 1996; 9(5): 211-4.

 ROP: Symptoms
• Results of severe ROP and premature birth
may produce some of the following signs
 White pupils (Leukocoria)
 Abnormal eye movements (Nystagmus)
 Crossed eyes (Strabismus)
 Severe nearsightedness (Myopia)
 Normal Eye Development

• From 16 weeks to birth, retinal blood vessels grow

out from the optic nerve to reach the peripheral
retina.
• The last twelve weeks of a normal 40 week
gestation are crucial in the development of fetal
eyes.
 Development: In premature babies

• In premature infants, the normal growth of blood

vessels stops.
• The area without adequate blood supply emits a
chemical trigger to stimulate growth of the
abnormal vessels.
• These vessels lead to a formation of a ring of scar
tissue attached to both the retina and the vitreous
gel that fills the center of our eyes.
• As the scar contracts, it may pull on the retina
creating a retinal detachment.
• Regardless of the gestation age at birth,
ROP seems to occur at about 37 to 40
weeks.
 Severity of the disease
Stage 1

Demarcation Line
• A line that is seen at the
edge of vessels, dividing
the vascular from the
avascular retina.
• Retinal blood vessels fail to
reach the retinal periphery
and multiply abnormally
where they end .
 Stage 2
Ridge
• The line structure of
stage 1 acquires a
volume to form a ridge
with height and width.
 Stage 3
Ridge with extra-retinal
fibrovascular proliferation
• The ridge of stage 2 develops
more volume and there is
fibrovascular proliferation into
the vitreous.
• This stage is further subdivided
into mild, moderate and severe,
depending on the amount of
fibrovascular proliferation
 Stage 4

• Partially detached retina.

• Traction from the scar produced by bleeding,
abnormal vessels pulls the retina away from the
wall of the eye.
 Stage 5

• Completely detached retina and the end stage

of the disease.
• If the eye is left alone at this stage, the baby can
have severe visual impairment and even
blindness.
 ROP: Anatomical Location

• The area of the retina affected by ROP is

divided into three zones
 Zone 1

• It is the most centrally located, and ROP

develops in this zone if the retina in this area is
most underdeveloped
• Zone 1 is more severe compared with disease
limited to zones 2 or 3
 Zone 2

It is the intermediate zone where blood vessels

often stop in ROP
 Zone 3

It is the peripheral zone of the retina, where

vessels are absent in ROP, but present in
normal eyes.
ROP:Location of Zones
 ROP:Diagnosis

• The only way to diagnose that baby has ROP is an eye

exam by an ophthalmologist at 4 weeks of age.
 ROP: Treatment

• Treatment for ROP depends on the stage and

severity of the condition.
• The milder stages of the disease typically resolve
themselves on their own, and do not require
treatment.
• If the disease has progressed to a point where the
baby's vision is at risk, treatment is required
 Treatment Modalities

• The treatment’s goal is to destroy the retina

that is deprived of retinal vessels.

• This helps to shrink the new vessels and

prevents the formation of dense scars that
usually follow
 Laser Photocoagulation

• Laser photocoagulation is the most common

treatment modality.
• A laser is directed to a designated spot to
destroy abnormal vessels and seal leaks.
• Laser photocoagulation is the preferred method
of treatment by surgeons, because there is little
postoperative pain and swelling
 Cryotherapy
• Cryotherapy can be used to treat threshold ROP
but is not the preferred
• It involves destroying abnormal tissue by freezing
and is often used to treat Grade III ROP
• Cryotherapy reduces the risk for retinal
detachment from 43% to 21%.
Drawback
• Cryotherapy also causes significant swelling of the
eye and eyelid, which makes postoperative
assessment difficult.
 Other treatments
• Scleral buckle and vitrectomy are also
commonly used for severe stage 4 and stage 5
retinopathies.
Vitrectomy
This is a complex procedure, which involves the
use of microscopic instruments to remove the
vitreous from the eye and replace it with a
saline (salt) solution.
 ROP:Complications
• Poor vision
• Myopia
• Premature infants with ROP have a high risk
for strabismus and amblyopia.
• Infants with regressed ROP are at risk for eye
problems as they grow. These are called late
complications of ROP
• Those with Stage V also have a 30% risk for
developing angle closure glaucoma.
 Prevention

The most effective prevention of retinopathy

of prematurity is prevention of premature
birth
 Prevention
• Strict control of oxygen use
•Training of all NICU staff
•Continuous Oxygen saturation monitoring
•Pulse oxymetri saturation limits 88 to 92%
•Restrictive use of O2 during resuscitation
•Avoid wide swings in oxygen delivery (e.g.
positioning, during suctioning, surfactant
administration)
 …. prevention

• Prevent infections
• Rational transfusion policy
• Breastfeeding
• No role of any drug
 Screening examination
• Parents should be informed about ROP
• In developing countries needs to use
criterias that are appropriate for their local
population as the findings suggest that
larger, more mature infants are developing
severe ROP ( pediatrics 2005; 115:e518-
e525)
 …. screening
• Timing of screening :
•4-6 weeks of postnatal age
•31-33 weeks of postconceptional age
• Eye examinations should be repeated every
1-2 week intervals until retinal
vascularization is complete into zone 3
• Threshold disease : treat within 72 hours to
prevent retinal detachment
 …. screening
• The American Academy of Pediatrics & the
American academy of Ophtalmology, 2006
•Infants with BW < 1500 g or GA < 32
weeks with or without supplemental
oxygen, or
•Infants with BW 1500-2000 g or GA >
32 weeks with unstable clinical course,
requiring cardiorespiratory support
 …. screening
• The American Academy of Pediatrics & the
American academy of Ophtalmology, 2006
•Infants with BW < 1500 g or GA < 32
weeks with or without supplemental
oxygen, or
•Infants with BW 1500-2000 g or GA >
32 weeks with unstable clinical course,
requiring cardiorespiratory support
 …. screening
• Timing of screening :
•4-6 weeks of postnatal age
•31-33 weeks of postconceptional age
• Eye examinations should be repeated every
1-2 week intervals until retinal
vascularization is complete into zone 3
• Threshold disease : treat within 72 hours to
prevent retinal detachment
 Timing of eye examination based on
gestational age at birth
Gestational age birth Age at initial examination Age at initial examination
(weeks) (week) (week)
postmenstrual chronologic
22 31 9
23 31 8
24 31 7
25 31 6
26 31 5
27 31 4
28 32 4
29 33 4
30 34 4
31 35 4
32 36 4